fracturas diafisarias de cúbito y radio en adultos

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Diaphyseal Fractures of the Radius and Ulna in Adults

Joshua P. Moss, MD*, Donald K. Bynum, MDDepartment of Orthopaedic Surgery, University of North Carolina, CB 7055, 3157 Bioinformatics Building,

Chapel Hill, NC 27599-7055, USA

Diaphyseal fractures involving the radius and

ulna, so called ‘‘both-bone’’ or ‘‘double-bone’’

forearm fractures are common orthopedic injuries.

These injuries can result in significant loss of

function if inadequately treated. As the upper

extremity serves to position the hand in space,

loss of forearm motion and/or muscle imbalance

resulting from a poorly treated fracture can be

particularly debilitating. Preservation of the ana-

tomic relationships of the proximal and distal

radioulnar joints as well as the interosseous space

is critical to preserving function. This article pro-

vides an overview of the management of diaphy-

seal fractures of the radius and ulna in adults.

History

Historically, both-bone forearm fractures, like

nearly every other orthopedic injury, were treated

with closed manipulation and casting; however,

even the best published results of this technique

were far from perfect. Evans [1] reported a series

of five patients treated with closed reduction and

casting. His technique was reliant upon a tuberos-

ity view radiograph of the proximal radius, which

revealed the relative pronation or supination of

the proximal fracture fragment (Figs. 1 and 2).

Reduction was thus performed to match the fore-

arm rotation. His results still revealed more than

50 degrees of loss of forearm rotation in more

than 30% of patients.

Early efforts with operative techniques resulted

in poor outcomes and disappointing results. In-

adequate internal fixation techniques were often

cited as the main cause of failure. Knight and

Purvis [2] reported a high rate of unsatisfactory

outcome with early internal fixation techniques

involving onlay grafts, intramedullary Kirschener

wires, and inadequate plate fixation (Fig. 3).

Before the AO (Association for Osteosynthesis)

revolution, many different fixation techniques

were used for both bone forearm fractures. Smith

and Sage [3] developed an intramedullary nail

for the forearm, augmenting their fixation with a

long-arm cast for 3 months. Still, they reported

a nonunion rate of 6.2%. Sargent and Teipner [4]

published a series of 29 both-bone forearm fractures

treated with double, orthogonal plates on both theradius and ulna (Fig. 4). Their reported union rate

was 100%, however their refracture rate following

hardware removal was 29%. In a subsequent study,

Teipner and Mast [5] compared double plating to

single plating using AO techniques. They concluded

that double plating offered no advantages while

requiring more surgical time, so they abandoned

double plating. In 1964, Burwell and Charnley [6]

published a case series demonstrating the use of

noncompressing plates in a series of 231 both-

bone forearm fractures. Despite excellent func-

tional results, their rate of nonunion was 10%.

In the mid 1970s, the concepts of internal

fixation promoted by AO/ASIF (Association for

the Study of Internal Fixation) began to take

hold. It is reasonable to conclude that treatment

of diaphyseal fractures of the forearm has

benefited more from the advances in modern com-

pression plating techniques than the treatment of

any other skeletal injury. Anderson and col-

leagues [7] published a paper in 1975 touting the

benefits of the AO/ASIF technique in treating di-

aphyseal forearm fractures. They noted roughly97% union in all fractures, results that have

* Corresponding author.E-mail address: [email protected] (J.P. Moss).

0749-0712/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.hcl.2007.03.002 hand.theclinics.com

Hand Clin 23 (2007) 143–151

mailto:[email protected]

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been duplicated in multiple publications. Internal

fixation with compression plating has since been

accepted as the gold standard treatment for diaph-

yseal both-bone forearm fractures.

Patient presentation and initial evaluation

Forearm fractures can present as a result of

low-energy trauma, such as falls, sporting injuries,and low-velocity gunshot injuries, or high-energy

trauma, such as falls from a height, motor vehicle

crashes, and high-energy gunshot injuries. Local

pain and deformity are the rule, often accompa-

nied by soft-tissue injury corresponding to the

energy of the injury. Open fractures are common

and can occur even with low-energy injuries given

the subcutaneous anatomy of the ulna. Less

commonly, patients will present with one or

more neurological or vascular deficits.

A meticulous history and physical exam are

required so that subtle neurovascular deficits arenot overlooked during the period of acute pre-

sentation. Orthogonal radiographic views of the

forearm, including the elbow and wrist, should be

obtained to thoroughly evaluate the location and

type of fracture as well as to rule out injuries to

the wrist or elbow. Acutely, any open wound

should be briefly irrigated with normal saline todecrease gross contamination, and then dressed

with a sterile dressing while awaiting definitive

treatment. Any gross deformity should prompt

a provisional closed reduction, followed by appli-

cation of a well-padded sugar-tong splint. In the

multiply injured patient who may be delayed

operative fixation, it is crucial to frequently assess

the integrity of the patient’s skin, particularly at

the edges of the splint or cast where pressure

concentration can quickly lead to skin breakdown

and ulceration.

Nonoperative management

Isolated nondisplaced or minimally displaced

(less than 50%) fractures of the ulna can effectively

Fig. 1. Technique for shooting the tuberosity view.

Fig. 2. Typical contours of the bicipital tuberosity with

varying degrees of forearm rotation.

Fig. 3. Onlay graft technique used by Knight and

Purvis.

Fig. 4. Double plating technique used by Sargent and

Teipner.

144 MOSS & BYNUM



be treated with immobilization. A long-arm cast or

functional fracture brace may be used. Completely

nondisplaced fractures of the radius can be treated

with 4 to 6 weeks of immobilization in a long-arm

cast. However, time to union may be delayed due

to the intact ulna preventing coaptation of theradius. There are few indications for closed treat-

ment of both-bone forearm fractures in adults.

Only for a critically injured patient or a patient

with severe medical comorbidities such that oper-

ative risk is prohibitive should closed methods be

considered. The literature is clear in concluding

that, all things being equal, closed treatment of

both-bone forearm fractures leads to higher rates

of nonunion, malunion, and crossunion, resulting

in a higher rate of poor functional outcomes.

Operative management

Fractures involving both bones of the forearm

should be treated with anatomic open reduction

and rigid internal fixation (ORIF) to restore the

forearm axis and allow for early postoperative

motion. The purpose of the so-called forearm axis

(elbow, forearm, and wrist) is to position the hand

in space. To that end, the contributions of elbow

and wrist motion are obvious, but many consider

the forearm a joint in and of itself. Forearmsupination and pronation are important compo-

nents of the upper extremity’s ability to position

the hand. Maintenance of anatomic radial bow

and the interosseous space are thus important

treatment goals. Dynamic compression plating

has been considered the gold standard treatment

since the AO/ASIF group released their Manual of

Internal Fixation in 1979 [8].

The majority of forearm fractures can be

approached with the patient supine and the upper

extremity abducted onto a hand table. The volarforearm is easily approached in this position, but

approach to the ulna will require elbow flexion. If

a dorsal approach is indicated in a supine patient,

adducting the arm closer to the body allows more

shoulder internal rotation and thus easier access to

the dorsal forearm. Prone positioning of the

patient allows ready access to the dorsal forearm

as well as the subcutaneous border of the ulna. To

reduce the incidence of crossunion, the radius and

ulna should be approached separately, avoiding

exposure of the interosseous space if at all possible.

Given the subcutaneous nature of the fulllength of the ulna, surgical access to that bone is

relatively simple. The only neurovascular structure

in immediate danger during surgical approach to

the ulna is the dorsal branch of the ulnar nerve.

This nerve is in play during exposure of the distal

third of the ulna. Mok and colleagues [9] found

that the ulnar nerve exits the deep volar fascia to

course dorsally over the ulna at a mean distanceof 2.9 cm proximal to the ulnar styloid. Doyle

and Botte [10] describe the nerve’s exit from the

deep fascia as 5 cm proximal to the proximal

edge of the pisiform. Care should be taken when

approaching the distal third of the ulna to dissect

and preserve this important cutaneous nerve

(Fig. 5).

The radius, with its surrounding muscular enve-

lope and closely associated neurovascular struc-

tures, is more difficult to approach at all levels, but

particularly the proximal third. One of two work-horse approaches to the radius are typically used,

either the dorsolateral Thompson or volar Henry

approach.

The Thompson approach is often considered

best applied for exposure of the proximal and

middle thirds of the radius. One advantage of this

exposure is that it allows better reconstitution of

the dorsal and radial bows when treating a long

oblique or comminuted midshaft fracture. This is

because application of a contoured (pre-bent)

compression plate to the tension side of the

fracture allows compression across both the volarand dorsal cortices. Proximally, the Thompson

approach uses the interval between the extensor

carpi radialis brevis and the extensor digitorum

communis, exposing the supinator muscle in the

proximal third of the forearm (Fig. 6).

The posterior interosseous nerve can be iden-

tified as it runs perpendicular to the fibers of the

supinator approximately three finger breadths

distal to the radiocapitellar joint. Care is then

taken to supinate the radius, allowing safe eleva-

tion of the supinator from its insertion to protectthe posterior interosseous nerve. This allows

exposure of the proximal and middle thirds of

the radius. The proximal exposure, however, is

not extensile, as further proximal dissection puts

the posterior interosseous nerve at risk as it

crosses the neck of the radius directly on bone.

The distal third of the Thompson approach is

relatively subcutaneous. The inter-nervous inter-

val between the radial outcropper muscles and the

brachioradialis is bluntly developed. The superfi-

cial radial nerve must be identified and protected

as it passes through this interval.Thevolar Henry approach to theradius is a truly

extensile approach. The incision passes from the

145DIAPHYSEAL FRACTURES OF THE RADIUS AND ULNA



lateral bicipital sulcus distally toward the radialstyloid. Proximally, this approach exploits the

interval between the brachioradialis laterally and

the biceps and brachialis tendons medially. The

lateral antebrachial cutaneous nerve is identified

and protected and the lacertus fibrosus is divided.

The recurrent branch of the radial artery courses

directly across the field and requires ligation to

continue the approach. Once this interval is de-

veloped, the radial nerve and its branches are

identified. As with the Thompson approach, the

radius is then maximally supinated to allow eleva-tion of the supinator from its insertion. This affords

protection to the posterior interosseous nerve as it

passes deep between the two heads of the supinator.

Following elevation of the supinator, the mobile

wad is retracted laterally to provide access to the

proximal half of the radius. More distally, the

radial artery crosses from medial to lateral across

the radius, then assuming a course deep to the

brachioradialis, adjacent to the superficial radial

nerve. The artery should be protected during distal

dissection. To access the middle third of the radial

shaft, the radial insertion of the pronator teresshould be taken down. Pronation of the forearm

allows access of the lateral cortex of the middle and

distal radial shaft. For full exposure of the middleand distal volar cortices of the radius, the radial

origins of the flexor digitorum superficialis and

flexor pollicis longus must be elevated. Finally, the

pronator quadratus covers the most distal aspect of

Fig. 5. Anatomy of the dorsal cutaneous branch with exposure of the ulna. (From Doyle JR, Botte MJ. Surgical anat-

omy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 476; with permission.)

Fig. 6. Surface landmarks for the dorsal approach to the

radius. (From Doyle JR, Botte MJ. Surgical anatomy of

the hand and upper extremity. Philadelphia; Lippincott

Williams and Wilkins. p. 473; with permission.)

146 MOSS & BYNUM



the volar radius. This too must be elevated from its

radial insertionto allow complete volar bony access

(Figs. 7 and 8).

Once adequate bony exposure has been ob-

tained, the fractures must be reduced. Given the

proximal and distal linkage of the two forearmbones, reduction of one can make reduction of the

other quite difficult. It is generally easiest to reduce

the less comminuted of the two bones first, thus

establishing length and rotation. Alternatively, if

both bones are significantly comminuted, indirect

reduction by traction and manipulation may be

performed and then maintained by a fracture dis-

tractor or provisional plate application. Once pro-

visional fixation is applied, forearm rotation range

of motion should be assessed to confirm anatomicalignment. Intraoperative fluoroscopic spot views

can also be of assistance in confirming reduction.

For definitive fixation, dynamic compression

(DC) or limited contact dynamic compression

Fig. 7. Anatomy of the radial recurrent artery during volar proximal radial exposure. (From Doyle JR, Botte MJ. Sur-

gical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 439; with permission.)




(LCDC) plates should be used whenever possible.

These plates are generally considered to be, in

most cases, of sufficient strength to allow func-

tional loading while bony healing progresses.

Depending on the comminution and obliquity of

the fracture, most diaphyseal forearm fractures

should require six to eight cortices of fixation

above and below the fracture. However, Lindvall

and Sagi [11] obtained a 97% union rate using

four cortices of fixation on either side of the frac-

ture with plates of varying lengths. They notedthat as the ratio of fracture working length to

plate length increases, stability diminishes (Fig. 9).

If possible, an interfragmentary screw shouldbe added, although this is obviously not possible

with transverse fractures. Compression should be

performed using standard AO compression plate

technique.

An alternative technique to compression plating

is intramedullary nail fixation. Interference nails

have long been considered inferior to compression

plating because of their relative lack of rotational

control and poor ability to maintain length in

comminuted fractures. However, the recent de-

velopment and implementation of locked intra-medullary nail systems provides an effective

alternative to plating. Weckbach and colleagues

[12] obtained 97.5% union in 40 forearm fractures

treated with the ForeSight locked IM nail. Gao

and colleagues [13] reported 100% union in 32 frac-

tures treated with the ForeSight system (Fig. 10).

Indications for intramedullary nail fixation of

diaphyseal forearm fractures include poor soft-

tissue integrity, segmental fractures, multiple in-

juries, and severe osteopenia. Contraindications

include active infection, medullary canal smaller

than 3 mm, and open physes. This technique canbe technically difficult, as the anatomic bow of the

radius and the serpentine shape of the ulna can

Fig. 8. Pronated view of the radius following volar

Henry exposure. (From Doyle JR, Botte MJ. Surgical

anatomy of the hand and upper extremity. Philadelphia;

Lippincott Williams & Wilkins. p. 469; with permission.)

Fig. 9. (B – C ) Four cortices of fixation on either side of

the (A) fracture, as performed by Lindvall and Sagi.

148 MOSS & BYNUM



require a pre-bend to be applied to the nails before

insertion. Also, the closed reduction can be diffi-

cult to obtain before nail insertion. Matching the

cortical diameters under fluoroscopic guidance is

a useful trick to obtain a more accurate reduction.

Once definitive fracture fixation is performed,

the tourniquet is released and hemostasis obtained.

Forearm fascia should never be closed, and the

wounds should not be closed under tension. Split-

thickness skin grafting or delayed closure is prefer-

able to wound dehiscence or skin flap necrosis

following an excessively tensioned closure.

Postoperatively, soft tissues should be rested

with a bulky forearm-based splint for 5 to 7 days.

Active elbow and digit motion should be encour-

aged during this period. Wrist and forearm motionwith light functional loading (ie, dinner fork)

should ensue immediately after the initial wound

check clinic visit. This level of function should be

maintained until radiographic and clinical signs of

union have been observed, usually after 12 to 16

weeks.

Hardware removal

Routine removal of forearm fracture hardware

should not be performed. There is a high compli-

cation rate associated with the removal of forearmhardware. Complications include refracture and

neurovascular injury. Mih and colleagues [14]

reported an 11% refracture rate following re-

moval of forearm hardware from 62 patients out

of an overall cohort of 175 patients treated with

ORIF for forearm fractures. Refracture occurred

at an average of 6 months from plate removal

with none occurring after 9 months following sur-

gery. Sixty-seven percent of the patients still had

residual symptoms despite hardware removal.

They reported a four times higher complication

rate in patients having undergone hardware re-

moval compared with those retaining their plates.

Dense scarring can place forearm neurovascular

structures at risk during any approach for revision

or hardware removal (Figs. 11 and 12).

Risk factors for fracture following hardware

removal include early plate removal (less than 1year after index procedure), fracture with initial

comminution, and plating with 4.5-mm hardware.

The use of 4.5-mm hardware has largely been

abandoned in treating both-bone forearm fractures.

The larger residual hole size following hardware

removal places the patient at a higher risk of

postoperative refracture. Compression plates of

3.5 mm have been accepted as the gold standard

for the treatment of most forearm fractures.

ComplicationsComplications of open treatment for both-

bone forearm fractures include nonunion,

Fig. 10. (A) Comminuted both-bone forearm fracture (B) treated with locked intramedullary nail fixation.




malunion, infection, and neurovascular injury.

Nonunion is rare following treatment of closed

fractures of the forearm. Multiple publications

have reported union rates of 97% to 100% with

anatomic compression plating. Open fracturesand fractures that are highly comminuted can

have an increased nonunion rate. Many advise

primary autologous bone grafting of forearm

fractures with greater than 50% comminution,

although both Wei and colleagues [15] and Wright

and colleagues [16] found no difference in union

rates regardless of whether comminuted diaphy-seal forearm fractures are grafted.

Matthews and colleagues [17] found, in their

cadaveric study, that coronal plane deformity of

the radius or ulna of 20 degrees or greater resulted

in at least a 30% reduction in forearm rotation.

Wilson and colleagues [18] reported that angular

malalignment and the related loss of forearm rota-

tion were the factors most often associated with

the inability to return to the same work following

injury. Combined angular malalignment of the ra-

dius and ulna of less than 40 degrees limited lossof forearm rotation such that patients usually re-

turned to the same occupation. Malunion is

avoidable if an anatomic reduction is maintained

with rigid internal fixation. Checking intraopera-

tive forearm range of motion can help prevent a re-

duction that decreases the interosseous space,

reducing motion. Malunion can also affect the ar-

ticulation of the proximal and/or distal radioulnar

joints resulting in pain and eventually arthrosis.

Corrective osteotomy may be indicated in the set-

ting of significant loss of motion or proximal/dis-

tal radioulnar joint symptoms.

Summary

In summary, both-bone forearm fractures are

common injuries in adults. They are routinely

treated with anatomic open reduction and internal

fixation with dynamic compression plating. Intra-

medullary rod fixation is an emerging technology.

Surgical exposure of the radius may be accom-

plished through either volar or dorsolateral ap-

proaches. The ulna may be easily exposed along

its subcutaneous border. Restoration of the radial

bow and interosseous space is important to

maintain forearm rotation. Hardware removal is

associated with a high rate of complication,

including refracture and neurovascular injury.

References

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Joint Surg Br 1951;33(4):548–61.

[2] Knight RA, Purvis GD. Fractures of both bones of

the forearm in adults. J Bone Joint Surg Am 1949;

31(4):755–64.

Fig. 11. Radial fracture following removal of hardware.

Fig. 12. Fracture following removal of 4.5 mm hardware.

150 MOSS & BYNUM



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shaft fractures by double-plating: a preliminary re-

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